As our next group of residents arrive at Telluride for the 10th Annual TelluridePatient Safety Educational Roundtable and Summer Camps, it is good to remember this message from these North Carolina pediatric intensivists who are trying to eliminate preventable harm:
“The big focus has been recognizing that
it’s a systems issue,” Norman said. “We’re really trying to remove the
blame from an individual provider and saying, 'How can we make the
system more efficient? How can we work toward delivering better, safer,
more efficient care?'”
What about when a doctor makes a mistake and everyone covers for them? Blacklisting, etc.?
ReplyDeleteNot good, obviously. The opposite of what we try to achieve.
ReplyDeleteIt's not so much a 'mistake' that we worry about, although a coverup certainly is cause for worry. The whole point is that humans make mistakes. What Robert Wachter and others are trying to think through is where to draw the line, in a just culture, between being hard on the problem and not the person, and demanding personal accountability when someone is careless or sloppy or worse. Because of course those kinds of people are the first to try to hide behind the just culture. (the last sentence is my own opinion).
ReplyDeletenonlocal MD